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Monday, October 03, 2005

Trying to Reform Graduate Medical Education, Again

Earlier this month in JAMA, Ludmerer and Johns published an important article on graduate medical education [Ludmerer KM, Johns MME. Reforming graduate medical education. JAMA 2005; 294: 1083-1087.]
Their important perspective is that the major problems afflicting graduate medical education (GME) date back about 100 years. The underlying problem is "a tradition of economic exploitation of house officers." Although basic to graduate medical education is learning to take care of patients by doing so, they argue that the demands on house officers to perform service have out-weighed educational aspects of training programs since the early 20th century. Furthermore, much of the service demanded of house officers has always been work that can be done by people other than doctors. In the 1920s and 1930s, it was "blood counts and urinalyses, transporting patients, drawing blood samples, and starting intravenous lines." A recent study showed that about one-third of modern house officers' time is spent on academies of "marginal or no educational value."
Also sobering is Ludmerer and Johns' listing of numerous reports, starting in the 1940s, calling for reform of graduate medical education and ending exploitation of house staff. For example, in 1940, there was the Report o the Commission on Graduate Medical Education. In the 1960s, there were the Millis and Coggleshall reports. Recently, there were reports by the Commonwealth Fund Task Force on Academic Health Centers, the Institute of Medicine Committee on the Roles of Academic Health Centers in the 21st Century, etc.
Ludmerer and Johns contend that recent regulations that limit working hours to 80 per week have not lessened stress on house officers, partially because few resources have been spent to allow the work that used to be performed by house officers working even longer hours to be done by somebody else.
Finally, Ludmerer on Johns call for accountability by the large organizations that control GME for the problems, and for them to act to make things better. (It is noteworthy that they do so, rather than rounding up the usual suspects, that is, the faculty and the house officers, who often take the rap for any perceived failings of GME.)

Hospitals - "Teaching hospitals will need to reengineer themselves so that they become less dependent on house officers for the provision of patient care...." "Teaching hospitals must also be prepared to use internal sources to provide additional funds for the support of GME." "Can they cap or reduce the size of the rapidly expanding administrative staffs found at so many of them? Have they adequately protected existing educational funds by making certain that federal GME payments (which go directly to teaching hospitals, not to training programs) are fully distributed to the intended recipients?" "Can the boards of teaching hospitals create compensation plans that reward senior hospital executives for the quality of medical work the institution does rather than for merely coming in below budget? We recognized that margins are necessary to fulfill mission, but bonuses and other financial incentives based solely on margins might tempt some administrators to skimp on mission."

National Regulatory Bodies - "National bodies that regulate GME remain largely rooted within the traditional service-oriented framework.... In addition, regulations may be issued that medical educators in the field consider unwise, and requirements are often implemented in a rigid, top-down fashion that denies program directors any flexibility or discretion. The ACGME's (Accreditation Council on Graduate Medical Education) adoption of the 80-hour work week policy is a case in point. The unhappiness among residency program directors with the new policy is palpable. A program directly recently said to one of us what dozens of program directors have told him privately in the last year: 'The ACGME has no idea of what life as a patient or resident is like today, and I am frightened of what we are now turning out.'" "The time has come for the ACGME to undertake a thorough review of its own performance."

3 comments:

Anonymous
said...

I already read the whole thing and agree. The problem in our institution is that we are already operating in the red. If we are going to expect our residents to do less work, where is the money going to come from? It's the usual conundrum of expecting those of us teaching at residency programs to do more with less money. We already take a pay cut compared to our private practice colleagues, so I won't be volunteering to take the money out of my salary. The authors do a good job of pointing out the problem, but do little in the way of proposing a solution. Again, if we're going to reform the system and give our residents more time for learning, where is the money going to come from?

Great point!The first thing is to get over thinking that the only source of additional money to make conditions better for house officers is the salaries of their teachers.Clearly teaching hospitals and academic health centers are under considerable outside economic pressure. Some of it they can't control. So one big question is why don't the organizations that pay for health care (with other people's money, a point that must be kept in mind) care more about the quality of the educational experience of doctors in training. Some of those same organizations profess to care an awful lot about quality and the latest fad, preventing medical errors. So why don't they care enough to pay adequately for better education that might improve quality and reduce medical errors?On the other hand, maybe we should also question why there isn't enough money in the budget of many teaching hospitals to improve the house staff experience. We know they get considerable money from Medicare for GME. But there has never been a requirement for accounting how they spend that money, so maybe it goes into the general budget and doesn't all come out again to support teaching. As Ludmerer and Johns hinted, we also should question how much hospitals spends on administration. There are plenty of stories on Health Care Renewal about hospitals that spend outrageous amounts on administration. Most recently, look at what had been going on at UMDNJ. Couldn't the money they spent on luxury cars and chauffeurs, on political contributions, on administrators' bonuses, on no bid, no work contracts have been better spent on GME?In summary, if you know your hospital's budget in detail, and are convinced there is nothing more than could be spent on improving the education of the next generations of physicians, then it's the payers you need to confront. But if the budget is a black box (or a black hole), maybe that is where you need to dig.

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